Asphyxia neonatorum (“pulselessness of the newborn”) is a lack of oxygen to the newborn. Synonyms used are peripartum asphyxia, neonatal asphyxia, or asphyxia at birth. The lack of oxygen causes respiratory failure, resulting in circulatory collapse.
What is asphyxia neonatorum?
The newborn responds to a poor oxygen supply with respiratory depression. The blood carries too much carbon dioxide, which cannot be exhaled and accumulates in the blood and organs. Under oxygen deprivation, metabolism switches to harmful anaerobic combustion. The pH value of the cord blood is acidic (acidosis from pH value less than 7.1 or 7.0). Further consequences of this can be more or less severe damage to various organs; but also malfunctions of the central and peripheral nervous system. About 20 percent of all neonatal deaths are due to asphyxia neonatorum. Premature infants have a twenty-fold increased risk of developing asphyxia. The risk increases the more factors can be combined and the more serious any single factor is. These include: Birth before 32 weeks gestation, being too small and too light for the gestational age. In twin or multiple pregnancies, the risk of asphyxia is increased for the second born twin – correspondingly for the subsequent born children – if the birth is delayed.
Causes
Oxygen deprivation can occur during pregnancy, during delivery, and shortly after birth. As a result of limited function of the placenta or entanglement with the umbilical cord, the umbilical vein of the unborn child is insufficiently supplied with oxygen, and thus its entire organism is insufficiently supplied with oxygen. Consequential damage can result from this. The unborn child has a lower weight and size gain and starts the birth with unfavorable conditions. Prenatally, mother and child can undergo an infection (example: toxoplasmosis). Medication, drug, alcohol, and nicotine use also increase the risk of asphyxia. During embryogenesis, undesirable developments may have occurred in the genetic blueprint: The baby starts into birth with poor prerequisites. A sugar disease of the mother also poses a risk for neonatal asphyxia. A very difficult birth can result in massive stress for the baby, causing it to turn blue and be born with gasping for breath. Premature babies are at increased risk for postnatal asphyxia due to their general immaturity, including the lungs. As a result of cerebral hemorrhage that has occurred due to the asphyxia, further asphyxia and respiratory and organ maladjustment may occur. After birth, the risk for asphyxia is due to immature lungs, infections of the lungs, pathogens present in the blood, or congenital heart defects. Birth injuries can lead to asphyxia.
Symptoms, complaints, and signs
The Apgar score is determined one, five, ten, and sixty minutes after birth to describe the newborn’s adjustment from life in the womb to life outside with its own breathing and metabolism. If the newborn baby comes into the world blue and with gasping breathing
(Asphyxia livida), the Apgar values one minute after birth (4-7) are correspondingly low. The newborn has an even less favorable prognosis if born as “white suspended animation” (Asphyxia pallida). Apgar scores are close to zero (0-3) one minute after birth. In circulatory failure, there is weak superficial respiration. There is an inadequate exchange of respiratory gases (carbon dioxide and oxygen). The blood cells in the arteries carry too little oxygen to supply the tissues: the partial pressure of oxygen decreases – not only in the arteries, but in all the tissues, which turn blue (cyanosis of the skin and mucous membranes). The carbon dioxide that is not exhaled leads to a clouding of consciousness, which can extend to coma. The heart rate drops below 100, respectively below 80 beats per minute. Muscle tone becomes flaccid. Grimacing or no crying takes the place of the expected vigorous crying.
Diagnosis and course of the disease
Asphyxia neonatorum represents a medical emergency that is met with extensive commitment to ensure the adaptation of respiration, metabolism, and organ function to life outside the womb. This phase may last a few days or several weeks. Whether, at what point, and to what extent damage to the central and peripheral nervous systems, autonomic nervous system, and organ function is sustained is not completely predictable and varies from case to case. The damage is classified as infantile cerebral palsy (ICP).
Treatment and therapy
During the course of early genetic development, it becomes apparent whether developmental disorders or developmental delays are present. The sucking and swallowing reflex is central to digestion: utilization of nutrients, growth, and weight gain. The innate reflexes are gradually replaced by voluntary movements. The infant should pass through the milestones within the time windows. The baby’s and toddler’s perceptions can be observed and become more sophisticated, as do their speech and motor skills. The pediatrician is trained to identify developmental delays within the U-examinations and to initiate physiotherapy, occupational therapy or early intervention measures as needed. Deficits become apparent in the form of crying, failure to thrive, and underweight. Even in the first few months, the infant does not perform certain genetically determined movement patterns in the intended manner. If the infant has a stiff, stretched trunk with an overextended head and legs, this indicates a movement disorder that will inevitably lead to subsequent motor deficits. Motor deficits are particularly obvious. They range from spasticity and diparesis of the legs to tetraparesis with an increasing need for care. Orthopedic aids range from a supply of insoles to orthoses, rollators, and wheelchairs. Severe spasticity is attempted to be controlled by anticonvulsants. If there are malpositions of tendons, ligaments and joints or contractures, surgery is required depending on the severity. These can occur in the hips, knees, ankles, feet, toes, shoulders, elbows and wrists. The more severe the course, the more neonatal reflexes remain and the less voluntary movements are possible. If the facial area is affected, there is increased salivation, slurred speech, misalignment of the teeth and deformation of the palate, and problems with chewing and swallowing. Furthermore, there are problems with the ventilation of nose, ears, bronchial tubes, so that increased infections are the result. Because of a lack of uprightness against gravity and insufficient muscle development due to nutrient undersupply (in the trunk as well as in the entire body), bronchitis and asthma occur more frequently, additionally supported by faulty control of the vegetative nervous system. Sensitivity disorders of the fingertips may exist. Hearing loss may occur. As a result of the incorrect control, a higher degree of defective vision is common, usually myopia. Myopia brings an increased risk of retinal detachment, retinal degeneration as twilight vision loss and as myopic macular degeneration. For premature infants, there is an additional risk of retinopathy of prematurity. In the middle eye segment there is the risk of premature cataract and glaucoma. Few examples are documented in the literature, according to which the retina in ICP can behave like in retinitis pigmentosa. In addition, optic atrophy may occur. Retinal detachment and retinopathy of prematurity are treated with laser, cryocoagulation, plomb, cerclage or pars plana vitrectomy depending on the severity. The cataract is removed and the eye is fitted with an artificial lens. For dry macular degeneration there is no therapy, for wet macular degeneration there are different methods to choose from – “injection into the eye”. The optic atrophy can continue from the ganglion cells ascending to the visual cortex. Retinitis pigmentosa and optic atrophy currently have no treatment option. The end result here is blindness.
Prevention
Pregnant women should keep a close eye on themselves and their pregnancy, eat a healthy diet, and refrain from all risks to themselves and their unborn babies. This includes medications, smoking, alcohol, drugs. She should attend preventive care appointments with her gynecologist.If she feels “that something is wrong,” she should follow up on this feeling and have the cause clarified. Some structural defects in embryogenesis trigger premature births. Sometimes it is also infections such as toxoplasmosis or the Candida fungus. If the woman belongs to the group of high-risk pregnant women, she should go to a well-equipped clinic. In the delivery room itself, it is hoped that the care provided by midwives, nurses and doctors will be good, so that if complications arise during labor, a cesarean section or forceps delivery can be made, depending on the stage of labor.
